Nursing
Nursing Diagnosis * Falls, risk for r/t diminished mental status aeb fractured R wrist, contusions on L knee and forehead, unsteady gait, “He’s fallen 3 or 4 times now but I don’t want to take away his independence so he lives alone at home”. “My dad often forgets words in mid sentence and will also misplace many of his personal items.” * Activity intolerance r/t hx of CVA aeb limited ROM of R arm. * Incontinence, urinary r/t hx of dementia, impaired mobility aeb “My dad cannot get to the bathroom in time and will often wet himself.”
Nursing Interventions * Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. Refer to physical therapy if needed.
Rationale: Fear of falling and repeat falling is common in the elderly population. Balance rehabilitation provides individualized treatments for persons with various deficits associated with balance. * When mobilizing the elderly patient, watch for orthostatic hypotension accompanied by dizziness and fainting.
Rationale: Postural hypotension can be detected in up to 30% of elderly patients. These methods can help prevent falls. * Encourage patients to wear glasses and use walking aids when ambulating.
Rationale: The use of walking and visual aids will help prevent falls and assist patients with an unsteady gait. * Complete a fall-risk assessment for older adults in acute care using a valid and reliable tool such as the Hendrich 2 Fall Risk Model.
Rationale: It is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk. This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls.
Expected outcome
5 measureable expected outcomes related to patient safety may caregiver * Client and family will change environment to minimize the risk for falls in
Nursing Interventions * Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. Refer to physical therapy if needed.
Rationale: Fear of falling and repeat falling is common in the elderly population. Balance rehabilitation provides individualized treatments for persons with various deficits associated with balance. * When mobilizing the elderly patient, watch for orthostatic hypotension accompanied by dizziness and fainting.
Rationale: Postural hypotension can be detected in up to 30% of elderly patients. These methods can help prevent falls. * Encourage patients to wear glasses and use walking aids when ambulating.
Rationale: The use of walking and visual aids will help prevent falls and assist patients with an unsteady gait. * Complete a fall-risk assessment for older adults in acute care using a valid and reliable tool such as the Hendrich 2 Fall Risk Model.
Rationale: It is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk. This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls.
Expected outcome
5 measureable expected outcomes related to patient safety may caregiver * Client and family will change environment to minimize the risk for falls in